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O R I G I N A L A RT I C L E

Difficult mask ventilation in obese

patients: analysis of predictive factors
A. LEONI 1, S. ARLATI 2, D. GHISI 3, M. VERWEJ 1, D. LUGANI 1
P. GHISI 1, G. CAPPELLERI 1, V. CEDRATI 1, A. EL TANTAWI ALI ALSHERAEI 1
M. POCAR 4, V. CERIANI 5, G. ALDEGHERI 1

1Department of Anesthesia, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy; 2Intensive Care Unit G. Bozza,
Niguarda Ca’ Granda, Milan, Italy; 3Department of Anesthesia, Intensive Care and Pain Therapy, University Hospital,
Parma, Italy; 4Department of Cardiac Surgery, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy; 5Department of
Surgery, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy

ABSTRACT
Background. This study aimed to determine the accuracy of commonly used preoperative difficult airway indices as
predictors of difficult mask ventilation (DMV) in obese patients (BMI >30 kg/m2).
Methods. In 309 consecutive obese patients undergoing general surgery, the modified Mallampati test, patient’s
Height/Thyromental distance ratio, Inter-Incisor Distance, Protruding Mandible (PM), history of Obstructive Sleep
Apnea and Neck Circumference (NC) were recorded preoperatively. DMV was defined as Grade 3 mask ventilation
(MV) by the Han’s scale (MV inadequate, unstable or requiring two practitioners). Data are shown as means±SD or
number and proportions. Independent DMV predictors were identified by multivariate analysis. The discriminating
capacity of the model (ROC curve area) and adjusted weights for the risk factors (odds ratios) were also determined.
Results. BMI averaged 42.5±8.3 kg/m2. DMV was reported in 27 out of 309 patients (8.8%; 95%CI 5.6-11.9%).
The multivariate analysis retained NC (OR 1.17; P<0.0001), limited PM (1.99; P=0.046) and Mallampati test (OR
2.12; P=0.009) as risk predictors for DMV. Male gender was also included in the final model (OR 1.87; P=0.06) as
biologically important variable albeit the borderline statistical significance. The model yielded a good discriminating
capacity (ROC curve 0.85). The four parameters were used to create an unweighted prediction score (ROC curve
0.84) with >2 associated factors as the best discriminating point for DMV.
Conclusion. Obese patients show increased incidence of DMV with respect to the undifferentiated surgical popula-
tion. Limited PM, Mallampati test and NC are important DMV predictors. (Minerva Anestesiol 2014;80:149-57)
Key words: Obesity - Ventilation - Anesthesia.

I nadequate ventilation, including difficult mask

ventilation (DMV) and difficulty or failure in
tracheal intubation, is one of the major contrib-
of surgical patients, especially during bag-mask
ventilation.2 It is well known that a 20% FRC
reduction with respect to normal values occurs as
or other proprietary information of the Publisher.

utors to morbidity and mortality associated with
anesthesia.1 Identifying patients at risk for prob-
lems with airway management is, therefore, a key
to optimal care. This is particularly true for the
obese patients as difficult airway management
is often reported in this ever-growing cohort
Comment in p. 143
the Body Mass Index (BMI) increases above 30
kg/m2. Also FRC decreases exponentially as the
BMI increases over 40 kg/m2, causing the obese
patients to breathe near their residual volume.3 A
more rapid and profound apnea-induced desatu-
ration therefore develops as a result of anesthe-
sia induction, despite adequate pre-oxygenation
levels.4 In addition, the increased fat deposition

Vol. 80 - No. 2 MINERVA ANESTESIOLOGICA 149

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LEONI Difficult mask ventilation in obesity: predictive factors
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in the pharynx increases the likelihood that re-
laxation of the upper airway muscles causes col-
lapse of the soft-walled oro-pharynx between
the uvula and epiglottis,5 thus making bag-mask
ventilation harder. Unfortunately, even the most
careful preoperative evaluation is unable to pre-
dict with sufficient accuracy the degree of these
dynamic changes, therefore reducing the ability
of the anesthetist to identify a difficult airway.
Routine awake intubation of morbidly obese
patients has been recommended to minimize
the occurrence of severe desaturation and life-
threatening hypoxia.6-8 However, this approach
is often cumbersome, may generate patient dis-
comfort and often reveals unnecessary.9 Finding
a bedside airway exam and history that are effec-
tive for predicting difficult mask ventilation is
still challenging. The prevalence of DMV in the
general adult surgical population varies between
0.07% and 5% accordingly with the definition
used.2, 10-13 A few independent DMV predictors
have recently been identified in the undifferenti-
ated adult population,2, 10-13 although compara-
ble studies lack among the obese patients.
The aims of the study were: 1) to estimate
the prevalence of DMV in a population of adult
obese patients scheduled for general anesthesia
and undergoing elective surgery; 2) to identify
the predisposing risk factors for DMV in the
obese population.
Materials and methods
After obtaining institutional review board ap-
proval and written informed consent, all consec-
utive adult (>18 years) obese patients (BMI ≥30
kg/m²) scheduled for general anesthesia, in the
period from April 2007 to December 2008, were
included in the study. The attending anesthesi-
ologist performed the preoperative assessment,
recruitment and induction of patients. The fol-
or other proprietary information of the Publisher.
lowing variables were prospectively collected:
Mallampati Pharyngeal Classification (without
phonation) modified by Samsson and Young,14
Inter-incisor gap and Thyromental distance (cm)
measured with the neck extended, BMI, Neck
Circumference (cm) measured at the level of
the thyroid cartilage,13-14 limited jaw protrusion
(≥class B accordingly with the jaw protrusion
150 MINERVA ANESTESIOLOGICA February 2014
test),15 dentition status and presence of beard. A
ruler was used to make all measurements. The
Thyromental distance was normalized by patient’s
height (height/TMD ratio) to increase its predic-
tive power.16 As the obese patients submitted to
bariatric surgery are at high risk for obstructive
sleep apnea (OSA), all patients with a history of:
1) apparent airway obstruction during sleep (i:
loud snoring (can be heard in adjacent rooms);
ii: witnessed apnea; iii: awaken with choking
sensation; iiii: frequent snoring) and 2) daytime
somnolence (i: frequent somnolence or fatigue
despite adequate “sleep”; ii. falls asleep easily in
a non stimulating environment) were consid-
ered positive for OSA accordingly with the ASA
guidelines for the peri-operative management
of patients with OSA.17 Also the use of CPAP
or bi-level positive airway pressure for release of
upper airway obstruction during sleep was di-
agnostic for OSA. As during the preparation of
the manuscript, the STOP-BANG scoring mod-
el,18 a highly sensitive, concise and easy to use
screening tool for moderate to severe OSA, was
validated in a large cohort of surgical patients, we
retrospectively reviewed the preoperative records
in order to improve the detection of patients at
high risk of OSA. Exclusion criteria were age <18
years, Mallampati class 4 (without phonation),
Inter-Incisor gap <3 cm, macroglossia, previous-
ly documented difficult intubation, ASA class-4,
recent oral/neck surgery, emergency surgery, in-
ability to keep the sitting position, craniofacial
abnormalities, severe cardio-respiratory disor-
ders (NYHA class 3-4),19 upper airway diseases
(i.e., maxillofacial fractures, tumors, etc.), cervi-
cal spine fracture. Macroglossia was defined as a
resting tongue protruding beyond the teeth or al-
veolar ridge.20 Patients with borderline predicted
difficult intubation were defined at preoperative
examination as those having a Mallampati class 3
plus at least one of the following criteria: Inter-
Incisor gap between 3-3.5 cm, limited mandibu-
lar protrusion (see above), Thyromental distance
6-6.5 cm. Patients were routinely monitored
by continuous electrocardiogram, non-invasive
blood pressure, pulse-oximetry and end-tidal
carbon oxide measurement. Before induction,
the patient was placed in a semi-recumbent posi-
tion with the head in the sniffing position.21, 22 A
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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
Difficult mask ventilation in obesity: predictive factors LEONI
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
100% oxygen mixture was administered by face-
mask until the end-tidal oxygen fraction reached
85%. Thereafter, anesthesia was induced by pro-
pofol (2–2.5 mg/kg) and succinylcholine (1 mg/
kg):23 both drug doses were calculated on pa-
tients’ total body weight (TBW). Mask ventila-
tion (MV), standard procedure in obese patients
during anesthesia induction in our institute, was
performed by a rubber reusable mask, with the
cricoid pressure applied by an assistant.24 Direct
laryngoscopy (DL) view was graded according-
ly with the Cormack-Lehane classification.25 A
McCoy No. 3 laryngoscope blade with the lever-
ing device in off position was used at the first
laryngoscopic attempt. If a difficult laryngoscopy
was encountered (Cormack and Lehane Grade 3
and 4), the lifting element of laryngoscope was
switched on and the score re-evaluated. This ap-
proach avoided the need for changing the blade
when difficult laryngoscopy occurred. We felt
this was important in an obese population with
a very short apnea time. Anesthesia services were
provided by the eight anesthesiology attending
staff members with assistance from two 4th year
residents. Impossible intubation was defined as
the inability to intubate the patient by DL de-
spite more than three attempts by an experienced
anesthesiologist. In general, the anesthesiology
resident initially attempted both MV and intu-
bation. If either DMV and/or difficult laryngos-
copy were found, the staff anesthesiologist veri-
fied each or both. In case of easy MV but difficult
intubation, the attending anesthetist decided to
perform awaken fiberoptic intubation or use al-
ternative techniques 26 (sequential technique). If
a patient had both difficult MV and difficult in-
tubation a laryngeal mask airway was inserted as
temporary mean for delivering oxygen and elimi-
nating carbon dioxide in the meanwhile that the
patient was awaken and fiberoptic intubation or
alternative techniques used. If the airway could
or other proprietary information of the Publisher.
not be maintained with extra-glottic devices, the
equipment for emergency needle cricothyrotomy
and percutaneous translaryngeal ventilation was
previewed in the operating room, while consid-
ering an emergency surgical cricothyrotomy.27
The primary outcome measure was the grade
of difficulty in achieving MV as assessed by the
four-point scale originally described by Han et
Vol. 80 - No. 2 MINERVA ANESTESIOLOGICA 151
Table I.—Mask Ventilation Scale (Han Scale).28
Grade Grade description
1 Ventilated by mask
2 Ventilated by mask with oral airway/adjuvant with or
without muscle relaxant
3 Difficult ventilation (inadequate, unstable, or requiring
two providers) with or without muscle relaxant
4 Unable to mask ventilate with or without muscle
relaxant
al.28 (Table I). As previously reported, the use
of muscle relaxant does not alter the MV grade
assigned.29
Statistical analysis
The Student’s t-test and the Kruskal-Wallis test
were used to compare continuous variables with
respectively symmetric and skewed distributions.
Categorical variables distributions were com-
pared by using chi-square or Fisher’s exact test.
The variables associated with Grade 3 MV were
selected by using multivariable logistic regression
models. All independent variables with an asso-
ciated P-value≤0.25 30 and variables of known
biological importance (e.g., age and sex) were in-
itially included into a full model A backward se-
lection procedure was used with a significant lev-
el of α=0.05. The area under a receiver operating
characteristic (ROC) curve was built to assess the
model’s predictive value with the Youden Index
used to define the best discriminating point.31
The positive and negative predictive values of
the final model (PPP and NPP) were calculated,
using the best discriminating point as cut-off.
Furthermore, if three or more factors were iden-
tified for DMV, a simple additive risk score was
built based on the presence (+1 point) of each
independent factor. Continuous variables were
included in the risk score after dichotomization
at their best discriminating values. A ROC curve
was then derived to assess the prognostic accu-
racy of the additive score.
The sample size calculations refer to the preva-
lence of DMV in obese patients as primary end-
point. Since 3.3% prevalence of DMV was observed
in patients with BMI>25 kg/m2,13 we assumed a
prevalence of 6% in patients with BMI≥30 kg/m2.
A sample size of at least 260 patients was requested
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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
LEONI Difficult mask ventilation in obesity: predictive factors
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
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in order to obtain a two-sided 95% confidence in-
terval with a width equal to 6%. Statistical analysis
has been performed using BMDP (BMDP® Stat
software, Inc, Los Angeles CA, USA).
Results
A total of 309 obese patients were consecu-
tively screened and included in the study. Once
in the operating room, one patient withdrew
consent for the study and was therefore ex-
cluded from the protocol. In 220 of the patients
(72%) bariatric surgery was the reason for gen-
eral anesthesia and endotracheal intubation.
The remaining 89 patients underwent vascular,
abdominal, urological or plastic surgical proce-
dures. The BMI value ranged from 30 kg/m2 to
78 kg/m2. On overall the M/F ratio was 1:2.6
with more than 70% females. Thirteen patients
were edentulous, while beard was present in 5
males only. The large majority of patients (265)
were in ASA class 3 (86%) and 54 patients
(17%) were in ASA class 2. The Mallampati pha-
ryngeal classification grouped 48.5% of patients
in class 1, 35.3% in class 2 and 16.2% in class
3. Limited jaw protrusion was present in 21% of
subjects (65 patients). The STOP-BANG scor-
ing model discovered 194 patients (62.8%) at
risk for undiagnosed OSA.
Among the 308 patients who completed the
study, after bag-mask ventilation 222 out of 309
patients were recorded in Han class 1 (72%), 59
in Han class 2 (19.2%), and 27 patients only in
Han class 3 (8.8%). None of patients was found
in Han class 4.
The rate of DMV was therefore 8.8% (95%CI:
5.6-11.9%). Direct laryngoscopic examination
was performed in 294 patients (95%), the re-
maining being ventilated by laryngeal mask due
to minimal surgical procedure.
or other proprietary information of the Publisher.
Table II.—Independent predictors for DMV in obese patients.
Factor Beta value
Grade 3 mask ventilation
Male gender 0.44
Mallampati classification 0.76
Neck circumference 0.16
Limited jaw protrusion 0.69
OR: Odd ratio; CI: Confidence interval.
152 MINERVA ANESTESIOLOGICA February 2014
At preoperative examination 21 patients were
identified at risk for borderline difficult intuba-
tion. However 19 patients only (6.5%) showed
a Cormack-Lehane class 3 view after direct
laryngoscopic examination. The Cormack-Le-
hane class 1 and 2 were found respectively in
68.3% and 25.5% of patients. The levering of
McCoy blade allowed for further reduction of
the number of difficult laryngoscopic views in
9 out of the 19 patients. Therefore a Cormack-
Lehane class 3 was confirmed in 10 patients only
of the 294 intubated (3.4%). Thirty-two out of
294 patients were at risk for borderline difficult
intubation (10.9%) but DMV occurred in only
one of them. Intubation by direct laryngoscopy
could be achieved in all DMV patients irrespec-
tively of their Cormack-Lehane classification.
Impossible intubation by DL occurred in 1 pa-
tient only but he was easy to ventilate by mask.
The patient was awakened and endotracheal tube
placement was achieved by fiberoptic bronchos-
copy. After univariate analysis neck circumfer-
ence (OR 1.22), Mallampati Score (OR=3.12),
male sex (OR=5.32) and mandibular protru-
sion (OR=1.89) highly differed between DMV
and non-DMV patients (P<0.0001), (Table
II). Age (OR=1.03; P=0.04) patient’s height
(OR=1.08; P=0.0003) and weight (OR?1.02;
P=0.004) and OSA symptoms (OR=1.81;
P=0.009) also reached statistical significance at
univariate analysis. All these variables therefore
entered the initial model together with lack of
teeth (OR=1.81; P=0.07) and ASA classifica-
tion (OR=2.81; P=0.09). Neck circumference
was entered as continuous variable after the test
for linearity. The multivariate analysis identified
neck circumference (P<0.0001), Mallampati
classification (P=0.009) and limited mandibular
protrusion (P=0.046) as independent predictors
of Grade 3 MV (Table II). Finally male sex en-
OR 95% CI P value
1.55 0.97-2.46 0.061
2.54 1.18-3.85 0.009
1.17 1.08-1.27 <0.0001
1.98 1.03-4.28 0.046
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Difficult mask ventilation in obesity: predictive factors LEONI

This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

tered the final model albeit of its borderline sta-
tistical significance (OR=1.55; P=0.06) together
with neck circumference (OR=1.17, P<0.0001),
Mallampati classification (OR=2.54, P=0.009)
and limited mandibular protrusion (OR=1.98,
P=0.046). The receiver operating characteristic
curve demonstrated an area under the curve of
0.85 with 0.19 and 0.98 of PPv and NPv respec-
tively at its best discriminating point.
Neck circumference, Mallampati classifica-
tion, limited mandibular protrusion and male
sex were used to create a prediction score with
neck circumference dichotomized at its best dis-
criminating point (46 cm).
The area under the curve for the receiver op-
erating characteristic curve was 0.84 (Figure
1). The association of three factors for DMV
showed 0.26 and 0.97 of PPV and NPV value
respectively at the best discriminating point. The
results of the unweighted risk scale are shown
in Figure 2. As no patients with zero risk fac-
or other proprietary information of the Publisher.
tors showed difficult mask ventilation they were
cumulated with those having one risk factor in
order to assess the odds ratio associated with the
degree of risk for two or more (OR=18.3), three
or more (OR=35.2) and four or more risk factors
(OR=64.9).
Discussion
The main finding of this study is that neck
circumference, Mallampati classification, lim-
ited mandibular protrusion and male sex were
independent predictors for DMV.
The incidence of DMV widely ranges in lit-
erature.2, 13 In our study an 8.8% of patients
showed DMV as defined by Grade 3 MV.28 This
prevalence is significantly higher than those re-
ported in the general adult population,13 so that
DMV occurs more frequently in the obese pa-
tients.
Our multivariate model yielded a good dis-

Figure 1.—Receiver operating curve (ROC) showing the relationship between sensitivity and 1-specificity in determining the
predictive value of the number of criteria (1 to 4) for difficult mask ventilation in obese patients.

Vol. 80 - No. 2 MINERVA ANESTESIOLOGICA 153

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LEONI Difficult mask ventilation in obesity: predictive factors

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Figure 2.—The risk of difficult MV based on the number of patient risk factors. Neck circumference was dichotomized at the best
discriminating point of 46 cm. The odds-ratio compares patient cohorts with a given risk level (i.e., ≥1, ≥2, etc.) to a patient with
0 risk factors. The x-axis demonstrates the odds ratio and 95% confidence interval using a log10 scale.

criminating capacity with a ROC curve area of
0.85. The risk factor score also helped to pre-
dict the MV outcome with a good accuracy. This
score is easy to obtain and may help the practi-
tioner to prepare for a possible episode of Grade
3 MV by identifying the patients at risk.
Limited jaw protrusion was an independent risk
factor associated with DMV in our patients. Sim-
ple maneuvers such as jaw thrust, head extension
and sniffing position are well know to augment
the distance between the mentum and the cervical
column, thus increasing the bony enclosure size.32
The relation between limited jaw protrusion and
or other proprietary information of the Publisher.
geal structures.33, 34 Thus the larger is the neck,
the more collapsible will be the pharynx and
hence the more difficult will result mask ven-
tilation. Our study also shows that the risk for
DMV rises linearly with the increase of the neck
circumference size (OR=1.17 per cm), as in pre-
vious literature.35
Mallampati classification independently pre-
dicts DMV in our patients. Mallampati classi-
fication reflects the amount of soft tissue in the
posterior oro-pharynx relatively to skeletal con-
straints. The larger is the amount of pharyngeal
tissue, the higher has been shown the Mallampa-

DMV was already suggested in previous litera-
ture.13 Our results emphasize the importance of
mandibular protrusion test as part of the standard
airway examination in obese patients.
The present study confirms neck circumfer-
ence as another important risk factor for DMV.
The thick/obese neck anatomy reflects the
amount of soft tissue surrounding the pharyn-
ti classification.36, 37 In our study, Mallampati 3
classification was significatively higher in DMV
than non-DMV patients (Table II).
Also male sex was found to influence DMV.
The higher difficulty in male mask ventilation
versus female might be related to fat deposition
differences, pharynx length and to higher neck
circumference.38, 39

154 MINERVA ANESTESIOLOGICA February 2014

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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
Difficult mask ventilation in obesity: predictive factors LEONI
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
Our study is at variance for previously identi-
fied risk factors of DMV as history of snoring/
OSA,2, 13 and lack of teeth.2 The presence of
beard,2, 13 did not enter the model due to the
very small number of bearded patients (5 pa-
tients). Our inability to define the history of
snoring/OSA as a predictor of DMV probably
results from the overlap of its predictive power
with that of independent risk factors such as
a thick neck anatomy and limited jaw protru-
sion. In a morphometric study evaluating upper
airway abnormalities of OSA patients,40 neck
circumference and mandibular ramus length
(protrusion) related to OSA. Otherwise our de-
liberate exclusion of patients with disproportion-
ate oro-pharyngeal anatomy (e.g., macroglossia)
or craniofacial abnormalities introduced a bias
that reduces the predictive value of OSA.
Our study suffers from several limitations.
Firstly, the true incidence of DMV is always
challenged by the ethical responsibility of the
anesthetist to divert very high-risk patients to
airway conservative management techniques
that preclude an attempt at mask ventilation.
Although our study included many high risk
patients, the very-highest risk population was
deliberately barred out so that the validity of our
statistical analysis may result altered.
Secondly, the heterogeneity of examiners and
laryngoscopists creates the potential for inter-
rate variability of both oro-pharyngeal classifica-
tions and laryngoscopic grade views. Moreover,
the observational nature of this study cannot
ensure that uniform and controlled conditions
were applied across all the MV attempts, al-
though the anesthesiology staff members were
highly experienced in the airway management of
obese patients. Nevertheless this heterogeneity
reflects the true state of routine clinical practice
therefore strengthening the study conclusions.
Thirdly, we could not achieve any statement
or other proprietary information of the Publisher.
about the relationship between difficult to venti-
late/difficult to intubate in the obese patients as
due to our small sample size. Moreover, the use
of the McCoy levering blade helped to improve
the initial laryngoscopic view in a few patients.
Fourthly, a 48.5% rate of Mallampati classifi-
cation 1 patients was reported in our study. This
is at little variance with the literature although
Vol. 80 - No. 2 MINERVA ANESTESIOLOGICA 155
Gonzales et al.39 have reported a 53% incidence
in their study investigating the intubation dif-
ficulties in obese patients. Nevertheless the high
rate of Mallampati class 1 in our study might
have introduced a bias and warrants caution
about results.
Moreover, we decided to apply the Sellick’s
maneuvre to all study patients, as it represents a
standard procedure in our Institution to reduce
the risk of gastric content aspiration in the obese
population. Although one study demonstrated
that Sellick’s maneuvre does not change “signifi-
cantly” the respiratory parameters,41 numerous
other studies have reported airway obstruction
during the application of cricoid pressure, result-
ing in difficult ventilation, difficult laryngosco-
py, difficult intubation, decreased tidal volumes
and increased inspiratory pressures.42 For these
reasons, some authors consider cricoid pressure a
potential cause of DMV.43, 44 Some effects of cri-
coid pressure on airways management are there-
fore not excludible in the obese patients enrolled
in the study.
Finally, a word of caution is needed about
several aspects of our analytical plan that specifi-
cally tailor the model fit to the observed data and
may not replicate in future data sets. So stepwise
selection procedure is sample dependent and it
may artificially enhance the performance of the
model. Dichotomizing predictors to optimal
cut points has similar consequences so that the
replication of our model in external samples is
strongly emphasized prior to clinical use. How-
ever, we believe that our results are valid as be-
ing supported by strong biological standpoints.
Our DMV predictors are in agreement with the
finding that the excess of soft tissue in obesity
increases the pressure outside the pharynx thus
reducing its transmural pressure that in turn
promotes the upper airway collapse.45
Conclusions
When approaching obese patients for general
anaesthesia, simple measurements of commonly
used preoperative difficult airways parameters
may help to identify those with difficult MV.
Neck circumference, Mallampati classification
and limited mandibular protrusions and male
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not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
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LEONI Difficult mask ventilation in obesity: predictive factors
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
sex are the most important risk factors for DMV.
Well-known predictors such as poor dentition
and OSA could not be demonstrated as risk fac-
tors in our study population. Further studies are
warranted for the prospective evaluation of our
results.
Key messages
—— Anticipation of difficult airways, in-
cluding difficult patient mask ventilation,
is crucial for the safe and efficacious airway
management.
—— In the present study, the prevalence
of DMV in a population of obese patients
(BMI value ≥30 kg/m2) was found as large
as 8.8% (95 CI%, 5.6-11.9).
—— This study shows that over the thresh-
old of 30 kg/m2, the risk of DMV is not af-
fected by the BMI value.
—— In the studied population, neck cir-
cumference, Mallampati classification, lim-
ited mandibular protrusion and male sex
were independent predictors for DMV in
the obese patients.
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Difficult mask ventilation in obesity: predictive factors LEONI

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Acknowledgements.—The authors would like to thank Ms Claudia Specchia, statistician.

Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed
in the manuscript.
Received on January 28, 2013 - Accepted for publication on September 25, 2013.
Corresponding author: A. Leoni, MD, Department of Anesthesia, IRCCS Multimedica Hospital, via Milanese 300, 20099 Sesto San
Giovanni, Milan, Italy. E-mail: albino.leoni@gmail.com
or other proprietary information of the Publisher.

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